Stakeholders' Perspectives on Strategies for the Recruitment and Retention of Primary Health Care Employees in Qatar: A Qualitative Approach.

This study explores the recruitment and retention conditions influencing primary health care (PHC) human resources for health (HRH) in Qatar and suggests strategies for their improvement. A qualitative design employing semistructured key informant interviews with PHC stakeholders in Qatar was utilized. Key interviewees were originally recognized, and snowball sampling was used to identify additional interviewees until reaching saturation point. Interview scripts were transcribed and then analyzed thematically using the Nvivo software package. Thematic analysis precipitated a number of themes. Under recruitment, the centrality of enhancing collaboration with academic institutions, enhancing extrinsic benefits, and strengthening human resources recruitment and management practices. Dedicated support needs to be provided to expatriate HRH especially in regard to housing services, children schooling, and streamlining administrative processes for relocation. Findings revealed that job security, continuous professional development, objective performance appraisal systems, enhanced job transparency, and remuneration are key retention concerns. The study provides a number of recommendations for the proper recruitment and retention of HRH. Health planners and decision makers must take these recommendations into consideration to ensure the presence of a competent and sustainable HRH in the PHC sector in the future.

Distribution and predictors of emergency department charges: the case of a tertiary hospital in Lebanon.

BACKGROUND: As health care costs continue to increase worldwide, health care systems, and more specifically hospitals are facing continuous pressure to operate more efficiently. One service within the hospital sector whose cost structure has been modestly investigated is the Emergency Department (ED). The study aims to report on the distribution of ED resource use, as expressed in charges, and to determine predictors of/contributors to total ED charges at a major tertiary hospital in Lebanon. METHODS: The study used data extracted from the ED discharge database for visits between July 31, 2012 and July 31, 2014. Patient visit bills were reported under six major categories: solutions, pharmacy, laboratory, physicians, facility, and radiology. Characteristics of ED visits were summarized according to patient gender, age, acuity score, and disposition. Univariate and multivariate analyses were conducted with total charges as the dependent variable. RESULTS: Findings revealed that the professional fee (40.9 %) followed by facility fee (26.1 %) accounted for the majority of the ED charges. While greater than 80 % of visit charges went to physician and facility fee for low acuity cases, these contributed to only 52 and 54 % of the high acuity presentations where ancillary services and solutions' contribution to the total charges increased. The total charges for males were $14 higher than females; age was a predictor of higher charges with total charges of patients greater than 60 years of age being around $113 higher than ages 0-18 after controlling for all other variables. CONCLUSION: Understanding the components and determinants of ED charges is essential to developing cost-containment interventions. Institutional modeling of charging patterns can be used to offer price estimates to ED patients who request this information and ultimately help create market competition to drive down costs.

Upscaling the recruitment and retention of human resources for health at primary healthcare centres in Lebanon: a qualitative study.

The sustainability of primary healthcare (PHC) worldwide has been challenged by a global shortage in human resources for health (HRH). This study is a unique attempt at systematically soliciting and synthesising the voice of PHC and community stakeholders on the HRH recruitment and retention strategies at the PHC sector in Lebanon, the obstacles and challenges hindering their optimisation and the recommendations to overcome such obstacles. A qualitative design was utilised, involving 22 semi-structured interviews with PHC experts in Lebanon conducted in 2013. Nvivo qualitative data analysis software was employed for the thematic analysis of data collected from interviews. Five comprehensive themes emerged: understanding PHC scope, HRH recruitment issues, HRH retention challenges, rural areas' specific challenges and stakeholders' recommendations. Analysis of stakeholders' responses revealed a lack of a unified understanding of the PHC scope impacting the capacity for appropriate HRH planning. Identified impediments to recruitment included the suboptimal supply of HRH, financial constraints and poor management. Retention difficulties were attributed to poor working environments, financial constraints and lack of professional development. There was consensus that HRH challenges faced were aggravated in rural areas, jeopardising the equitable access to PHC services of quality. Equitable access was also jeopardised by the reported shortage of female HRH in a sociocultural context where many females prefer providers of the same gender. The study sets the path towards upscaling recruitment and retention policies and practices through the endorsement of a nationally acknowledged PHC definition and scope, the sustainable development of the PHC workforce and through the implementation of targeted recruitment and retention strategies addressing rural settings and gender equity. Decision-makers and planners are urged to identify HRH as the most important input for the success of PHC programmes and interventions, especially in the growing fields of mental health and geriatric care.

A National Study on Nurses' Exposure to Occupational Violence in Lebanon: Prevalence, Consequences and Associated Factors.

BACKGROUND: Healthcare institutions have commonly reported exposure of employees, particularly nurses, to high levels of occupational violence. Despite such evidence in the Middle East Region, there is a dearth of national studies that have systematically investigated this phenomenon. This study investigates the prevalence, characteristics, consequences and factors associated with nurses' exposure to occupational violence in Lebanon. METHODS: A cross-sectional design was utilized to survey a nationally representative sample of 915 nurses registered with the Order of Nurses in Lebanon. Stratified random sampling by governorate was utilized. Individually-mailed questionnaires collected information on exposure to violence, degree of burnout and demographic/professional background. The main outcome variables were exposure to verbal abuse (never, 1-3, 4-9 and 10+ times) and physical violence (never, ever) over the past 12-months. Descriptive statistics were used to estimate prevalence of violence. Multivariable, binomial and multinomial regression models were carried out to investigate the correlates of exposure to verbal abuse and physical violence, respectively. RESULTS: Response rate was 64.8%. Over the last year, prevalence of nurses' exposure to verbal abuse was 62%, (CI: 58-65%) and physical violence was 10%, (CI: 8-13%). Among respondents, 31.7% of nurses indicated likelihood to quit their jobs and 22.3% were undetermined. Furthermore, 54.1% reported high levels of emotional exhaustion and 28.8% reported high levels of depersonalization. Compared to nurses with no exposure to verbal abuse, nurses reporting high exposure had high levels of emotional exhaustion (OR:6.4; CI:1.76-23.32), depersonalization (OR:6.8; CI: 3-15) and intention to quit job (OR:3.9; CI: 1.8-8.3). They further reported absence of anti-violence policies at their institutions (OR: 3; CI: 1.5-6.3). Nurses that were ever exposed to physical violence were more likely to be males (OR: 2.2; CI: 1.1-4.3), working day and night shifts (OR: 2.8; CI: 1.4-5.5) and subject to ten or more incidents of verbal abuse per year (OR: 46.7; CI: 10.1-214). CONCLUSIONS: An alarming two-thirds of respondents reported exposure to verbal abuse which was found to be a significant predictor of the three subscales of burnout, intention to quit and exposure to physical violence. The prevalence of exposure to physical violence is disconcerting due to its severe consequences. Policy and decision-makers are urged to use study findings for policy and practice interventions to create safe work environments conducive to nurses' productivity and retention.

Quality of Type II Diabetes Care in Primary Health Care Centers in Kuwait: Employment of a Diabetes Quality Indicator Set (DQIS).

Diabetes Mellitus is one of the major public health challenges, affecting more than 347 million adults worldwide. The impact of diabetes necessitates assessing the quality of care received by people with diabetes, especially in countries with a significant diabetes burden such as Kuwait. This paper aimed at piloting an approach for measuring Type II diabetes care performance through the use of a diabetes quality indicator set (DQIS) in primary health care. The DQIS for Kuwait was adapted from that developed by the National Diabetes Quality Improvement Alliance and the International Diabetes Federation. Five key care domains/measures were employed: (1) Blood glucose level measurement, (2) Cholesterol level measurement, (3) Blood pressure measurement, (4) Kidney function testing and (5) Smoking status check. The sample included the four major primary health care centers with the highest case load in Kuwait City, 4,241 patients in 2012 and 3,211 in 2010. Findings revealed the applicability and utility of employing performance indicators for diabetes care in Kuwait. Furthermore, findings revealed that many of the primary health care centers have achieved noteworthy improvement in diabetes care between 2010 and 2012, with the exception of smoking status check. The DQIS can help policymakers identify performance gaps and investigate key system roadblocks related to diabetes care in Kuwait.

Nurses' evaluation of physicians' non-clinical performance in emergency departments: advantages, disadvantages and lessons learned.

BACKGROUND: Peer evaluation is increasingly used as a method to assess physicians' interpersonal and communication skills. We report on experience with soliciting registered nurses' feedback on physicians' non-clinical performance in the ED of a large academic medical center in Lebanon. METHODS: We utilized a secondary analysis of a de-identified database of ED nurses' assessment of physicians' non-clinical performance coupled with an evaluation of interventions carried out as a result of this evaluation. The database was compiled as part of quality/performance improvement initiatives using a cross-sectional design to survey registered nurses working at the ED. The survey instrument included open ended and closed ended questions assessing physicians' communication, professionalism and leadership skills. Three episodes of evaluation were carried out over an 18 month period. Physicians were provided with a communication training carried out after the first cycle of evaluation and a detailed feedback on their assessment by nurses after each evaluation cycle. A paired t-test was carried out to compare mean evaluation scores between the three cycles of evaluation. Thematic analysis of nurses' qualitative comments was carried out. RESULTS: A statistically significant increase in the averages of skills was observed between the first and second evaluations, followed by a significant decrease in the averages of the three skills between the second and third evaluations. Personalized feedback to ED physicians and communication training initially contributed to a significant positive impact on improving ED physicians' non-clinical skills as perceived by the ED nurses. Yet, gains achieved were lost upon reaching the third cycle of evaluation. However, the thematic analysis of the nurses' qualitative responses portrays a decrease in concerns across the various dimensions of non-clinical performance. CONCLUSIONS: Nurses' evaluation of the non-clinical performance of physicians has the potential of improving communication, professionalism and leadership skills amongst physicians. For improvement to be realized in a sustainable manner, such programs may need to be offered in a staged and incremental manner over a long period of time with proper dedication of resources and timely monitoring and evaluation of outcomes. Department directors need to be trained on providing peer evaluation feedback in a constructive manner.

Quality of care in primary health care settings in the Eastern Mediterranean region: a systematic review of the literature.

PURPOSE: This systematic review aims at offering a comprehensive synthesis of studies addressing quality of care in the primary healthcare (PHC) sector of the Eastern Mediterranean Region (EMR). DATA SOURCES: A systematic search was conducted using Medline, Embase and Global Health Library (IMEMR) electronic databases to identify studies related to quality in PHC between years 2000 and 2012. STUDY SELECTION/DATA EXTRACTION: One hundred and fifty-nine (159) studies fulfilled the eligibility criteria. Each paper was independently reviewed by two reviewers, and the following information was extracted/calculated: dimension of care investigated (structure, processes and outcomes), focus, disease groups, study design, sample size, unit of analysis, response rate, country, setting (public or private) and level of rigor (LOR) score. RESULTS OF DATA SYNTHESIS: Most of the studies were descriptive/cross-sectional in nature with a relatively modest LOR score. Assessment of quality of care revealed that the process dimension of quality, specifically clinical practice and patient-provider relationship, is an area of major concern. However, interventions targeting enhanced quality in PHC in the EMR countries had favorable and effective outcomes in terms of clinical practice. CONCLUSION: These findings highlight gaps in evidence on quality in PHC in the EMR; such evidence is key for decision-making. Researchers and policy-makers should address these gaps to generate contextualized information and knowledge that ensures relevance and targeted high-impact interventions.

Prevalence and correlates of complementary and alternative medicine use among diabetic patients in Beirut, Lebanon: a cross-sectional study.

BACKGROUND: Patients with Type 2 Diabetes Mellitus (T2DM) are increasingly using complementary and alternative medicine (CAM) therapies due to difficulty in adhering to the therapeutic regimens and lifestyle changes necessary for disease management. Little is known about the prevalence and mode of CAM use among patients with T2DM in Lebanon. OBJECTIVE: To assess the prevalence and modes of CAM use among patients with T2DM residing in Beirut, Lebanon. METHODS: A cross-sectional survey of T2DM patients was conducted on patients recruited from two major referral centers in Beirut--a public hospital and a private academic medical center. In a face-to-face interview, participants completed a questionnaire comprised of three sections: socio-demographic, diabetes characteristics and types and modes of CAM use. Descriptive statistics, univariate and multivariate logistic regression analyses were utilized to assess the prevalence and correlates of CAM use, as well as whether the use was complementary or alternative to mainstream medicine. The main outcome in this study, CAM use, was defined as using CAM at least once since diagnosis with T2DM. RESULTS: A total of 333 T2DM patients completed the survey (response rate: 94.6%). Prevalence of CAM use since diagnosis with the disease was 38%. After adjustment, CAM use was significantly associated with a "married" status, a longer duration of T2DM, the presence of disease complications, and a positive family history of the disease. Folk foods and herbs were the most commonly used CAM followed by natural health products. One in five patients used CAM as alternative to conventional treatment. Only 7% of CAM users disclosed the CAM use to their treating physician. Health care practitioners were the least cited (7%) as influencing the choice of CAM among users. CONCLUSION: The use of CAM therapies among T2DM patients in Lebanon is prevalent. Decision makers and care providers must fully understand the potential risks and benefits of CAM therapies to appropriately advise their patients. Attention must be dedicated to educating T2DM patients on the importance of disclosing CAM use to their physicians especially patients with a family history of diabetes, and those who have had the disease for a long time.

Measuring the job stickiness of community nurses in Ontario (2004-2010): implications for policy and practice.

OBJECTIVE: Utilize the concept of stickiness to examine the retention of community nurses across time and draw comparisons by subsector, nurse group and work status. METHODS: Secondary analysis of College of Nurses of Ontario (CNO) registration database (2004-2010). Nurses' yearly registration records were linked to create a longitudinal database of nursing employment which was used to generate year-to-year stickiness figures. Analysis was carried out by sector/subsector of employment, nurse group and work status. RESULTS: Analysis revealed an active movement of nurses between the hospital and community sectors during the period of analysis, with a positive balance of 3002 nurses toward the latter. A wide variation in the stickiness of community subsectors of employment was noted, with those subsectors involving direct patient care and community visitation displaying relatively lower stickiness figures. Subsector stickiness increased with the offering of full-time jobs and the employment of Registered Nurses. CONCLUSION: Examining the working conditions and human resources management practices in the subsectors with lower stickiness, especially those involving patient care at home, and enhancing career stability of Registered Practical Nurses are priority issues. Decision-makers should support the offering of full-time jobs focusing attention on subsectors offering direct patient care in the community.

Factors associated with consulting a dietitian for diabetes management: a cross-sectional study.

BACKGROUND: Type 2 Diabetes (T2D) has reached epidemic levels in the Middle East region. Despite evidence that it improves health outcomes and saves health costs, dietary counseling for T2D remains grossly under-investigated in this region. The aim of this study was to assess the frequency and determinants of use of dietary counseling services by T2D patients in Lebanon and recommend corrective measures that may guide the planning, organization and delivery of care for chronic diseases in general and diabetes care in particular. METHODS: A non-experimental cross-sectional design was utilized to survey outpatients with T2D in two major health centers in Lebanon. Patients diagnosed with T2D were invited to complete a questionnaire consisting of five sections: socio-demographic characteristics, disease attributes, patients' perceptions regarding T2D management, practice of lifestyle modifications, and referral by a physician to a dietitian. The outcome of interest was the use of dietary counseling services by T2D patients at least once since their diagnosis. Descriptive statistics and logistic regression analyses were used to evaluate the frequency and determinants of dietary counseling services utilization. RESULTS: A total of 332 T2D patients completed the questionnaire (response rate 94.6%). Although 75% of study participants believed that dietitians can assist them in changing their dietary habits, only 38% had consulted with a dietitian. Among study participants, only 34% were referred to a dietitian by their physician. The main determinants of the use of dietary counseling services were referral by a physician (OR: 112.25; 95% CI = 42.74-294.84), the presence of outpatient social or private health insurance (OR: 5.86; 95% CI = 2.40-14.25) and the belief that a dietitian can assist in changing dietary habits (OR: 3.74; 95% CI = 1.33-10.54). CONCLUSIONS: The findings of this study show suboptimal use of dietary counseling services by T2D patients in Lebanon. Key determinants were physicians' referral, financial support for outpatient care, and patients' belief in the usefulness of dietary counseling. Suggested interventions entail enhancing the planning and organization of care through inter-professional collaboration between physicians and dietitians; promoting public financing for high quality outpatient care that includes dietary counseling; and promoting the value of dietary counseling and improving the public image of dietitians.

The retention of health human resources in primary healthcare centers in Lebanon: a national survey.

BACKGROUND: Critical shortages of health human resources (HHR), associated with high turnover rates, have been a concern in many countries around the globe. Of particular interest is the effect of such a trend on the primary healthcare (PHC) sector; considered a cornerstone in any effective healthcare system. This study is a rare attempt to investigate PHC HHR work characteristics, level of burnout and likelihood to quit as well as the factors significantly associated with staff retention at PHC centers in Lebanon. METHODS: A cross-sectional design was utilized to survey all health providers at 81 PHC centers dispersed in all districts of Lebanon. The questionnaire consisted of four sections: socio-demographic/ professional background, organizational/institutional characteristics, likelihood to quit and level of professional burnout (using the Maslach-Burnout Inventory). A total of 755 providers completed the questionnaire (60.5% response rate). Bivariate analyses and multinomial logistic regression were used to determine factors associated with likelihood to quit. RESULTS: Two out of five respondents indicated likelihood to quit their jobs within the next 1-3 years and an additional 13.4% were not sure about quitting. The top three reasons behind likelihood to quit were poor salary (54.4%), better job opportunities outside the country (35.1%) and lack of professional development (33.7%). A U-shaped relationship was observed between age and likelihood to quit. Regression analysis revealed that high levels of burnout, lower level of education and low tenure were all associated with increased likelihood to quit. CONCLUSIONS: The study findings reflect an unstable workforce and are not conducive to supporting an expanded role for PHC in the Lebanese healthcare system. While strategies aiming at improving staff retention would be important to develop and implement for all PHC HHR; targeted retention initiatives should focus on the young-new recruits and allied health professionals. Particular attention should be dedicated to enhancing providers' role satisfaction and sense of job security. Such initiatives are of pivotal importance to stabilize the workforce and ensure its longevity.